Clinical Review Nurse – Concurrent Review
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Job Description
Clinical Review Nurse conducting concurrent utilization reviews for Centene’s Medicaid and Ambetter members. Evaluating medical necessity, care levels, and discharge planning remotely.
Responsibilities:
- Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
- Review quality and continuity of care, acuity level, resource consumption, length of stay, and discharge planning
- Work with Medical Affairs and/or Medical Directors regarding member care
- Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
- Work with healthcare providers to approve medical determinations or provide recommendations
- Educate providers on utilization processes
- Provide leadership feedback on opportunities to improve level of care and medical necessity
- Review transfer and discharge plans to support timely transitions between levels of care and facilities
- Collaborate with care management on member referrals
- Comply with all policies and standards
- Perform other duties as assigned
Requirements:
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
- Minimum of 5 years nursing experience
- 2–4 years of related experience
- 2+ years of acute care experience required
- LPN state licensure required
- RN state licensure and/or compact state licensure for the State of Nevada required
- Applicants must reside in the Central, Mountain, or Pacific Time Zone
- LTACH, IPR, or SNF experience
- Clinical knowledge to determine overall health, treatment needs, and appropriate level of care preferred
- Knowledge of Medicare and Medicaid regulations preferred
- Knowledge of utilization management processes preferred
Benefits:
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
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